Medical Authorization For Child Page 2
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2MEDICAL AUTHORIZATION FORM
I, ___________________________, being the parent and/or legal
guardian of ________________________ (hereinafter, my child(ren)
do hereby authorize _____________________________ to seek and
obtain medical care for my child(ren) in the event that my child(ren)
need(s) medical care.
My child has the following allergies: __________________________.(if applicable)
I agree to be financially responsible for the cost of any medical care
provided to my child(ren) under this Authorization.
My health insurance carrier is ________________________ and my
Policy or Certificate number is _______________________.
Date ______________________
Signature of Parent (or Legal Guardian) _____________________
Witness Signature _____________________
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